Figure 7 - Students who think their body is too thin, about the right size, or too fat, by grade and gender (%)

Figure 8 - Grade 10 students who have ever tried cannabis, by gender and year of survey (%)

Figure 9 - Students reporting high levels of emotional problems by bullying involvement, by gender (%)

Introduction

The Health Behaviour in School-aged Children (HBSC) Study is a cross-national research study
conducted in collaboration with the World Health Organization. The study aims to increase understanding of health and its determinants in populations of young people. It involves health surveys
conducted with students in classroom settings, with a focus on the early adolescent years (ages 11-15). HBSC is administered every four years following a common research protocol.

The HBSC survey was first developed in 1982 by researchers from three European countries. The
project has since expanded to include 43 participating countries and regions from Europe, North
America and Israel. For the 2010 HBSC survey, the 8th in the cross-national series and 6th in Canada,
26,078 young Canadians from 436 schools participated. This summary booklet details some of the
key findings from this most recent survey. To obtain the full version of the report, please visit the HBSC study website.

Mental Health

The focus of the current report is the mental health of adolescents with contextual and
health/health behaviour variables being related to mental health. In congruence with current
approaches to mental health, we see the phenomenon along two dimensions ranging from
emotional (internalizing) to behavioural (externalizing) along one dimension and from positive to
negative along the other dimension.

Regardless of the way internalizing/emotional outcomes were examined, girls reported more
negative outcomes. They had higher levels of emotional problems and lower levels of emotional
well-being and life satisfaction than boys. Furthermore, while on many internalizing/emotional
variables, boys' scores remain fairly even across grades, scores for girls consistently worsen.

In contrast, externalizing/behavioural outcomes favour girls, who reported fewer
behavioural problems and more prosocial
behaviours than boys, although the size of
this gap is smaller than that for internalizing/
emotional outcomes. However, for both boys
and girls, externalizing/behavioural outcomes
worsened across grades such that older
problems and showed fewer prosocial
behaviours. A similar pattern occurs with life
satisfaction, in that it decreases across grades
and is consistently poorer for girls than for
boys. [Figure 1]

The contexts for young people's health

Four contexts figure prominently in the lives of young people: the home, the school, their peers,
and the neighbourhood. Each context may be the critical one for a particular adolescent with
respect to health/health behaviours and most particularly mental health.

The home setting

Figure 2 - Students who report being understood by their parents, by grade and gender (%)

The family provides the first socializing context in a young
person's development. Children learn and develop values
and norms based on those modeled, taught, and enforced
within the family environment. Younger students are much
more likely than older students to feel understood by their
parents, while boys at all grades are substantially more likely
than girls to agree they are understood by their parents.
An increase in the proportions of young people feeling
understood by their parents today relative to the early years
of the survey is substantial and suggests that youth have more
positive relationships with their parents than in the past.
[Figure 2]

The school setting

Figure 3 - Students reporting high levels of emotional well-being by school climate, by gender (%)

Youth spend a lot of their time at school. Thus it is not
surprising that their school-related experiences can have
a significant influence on their cognitive development, and
their physical and mental health. For example, a positive school
climate provides advantages to young people, while a negative
school climate creates distinct challenges for them. Boys who
report being in a school with a positive (high) school climate
also report levels of emotional well-being that are twice as
high as those boys who report being in a school with
a negative (low) school climate. The results are even more
dramatic for girls in which the differences are almost three
times higher. [Figure 3]

The peer context

Figure 4 - Students who find it easy or very easy to talk to same-sex friends about things that really bother them, by grade and gender (%)

From childhood to adolescence, peer relationships become
increasingly significant sources of support, companionship,
information, and advice. Peers can have short- and long-term
beneficial effects on social, cognitive, and academic adjustment. Reported friendship quality for adolescents tends to be
gender-related. Girls, for instance, remain more comfortable
than boys talking to same-sex friends about things that really
bother them [Figure 4]. A similar gender pattern is found for
best friends, while boys, in contrast to girls, have less difficulty
in talking to opposite-sex friends, at least in Grades 6-7.

The neighbourhood

Neighbourhoods represent key environmental settings
for youth, as policies, physical spaces and structures, and
cultural, social, and interpersonal interactions that occur in
these environments influence their subsequent behaviour, and
ultimately their health experiences. Vacant or shabby housing
can be an indicator of unfavourable neighbourhood conditions.
Such housing was perceived to be at least a minor problem in
29% of the elementary schools, 22% of high schools, and 41%
of the schools serving mixed grades. The peak surrounding
mixed schools is important, as it reflects lower socio-economic
conditions surrounding those school communities that are
required to combine school grades. [Figure 5]

Young people's health behaviours and health outcomes

Health behaviours and health outcomes encompass a range of variables that can be summarized
under the four broad headings of injury, healthy living and healthy weights, substance use and
risky behaviour, and bullying and fighting. Healthy living and healthy weights includes physical
and sedentary activity in addition to food consumption and measures of overweight/obesity
(both measured and self-perceived, only the latter being measured by HBSC). Risky behaviour
and substance use relates to consumption of alcohol, smoking of cigarettes, and use of illegal
substances (most notably cannabis), as well as sexual behaviour.

Injury

Injury is recognized as a leading health public health issue in populations of young people around
the world. Because of the enormous burden of injuries in terms of pain and suffering, permanent
disability and even death, the Government of Canada has identified injury as a major prevention
focus. Injuries are costly to society in terms of health care
expenditures and time lost from productive activities for both
adolescents and the adults who care for them when they are
injured. Context plays a role in the nature and effects of these
relationships. Injuries that occur in different settings and contexts might have very different effects on standard indicators
of mental health.

Figure 6 shows the overall proportions of students who
reported at least one injury requiring medical treatment over
the past year. Across the grades, 42 to 47% of boys reported
experiencing at least one such injury, compared to 35 to 40%
of girls. In every grade, boys reported more injuries than girls.
There was no strong trend in the occurrence of injuries across
the five grades.

Healthy living and healthy weights

Between 19 and 26% of boys are physically active for at least 60 minutes on a daily basis. Only 11
to 20% of girls achieve this same criterion. The proportion of students who are physically active at
this level declines between Grade 6 and Grade 10 within boys and girls.

According to the 2010 HBSC findings, 16 to 24% of boys and 9 to 14% of girls believe that their
body is too thin. Within boys these rates increase by 8 percentage points from Grade 6 to Grade 10,
and within girls these rates decrease by 5 percentage points from Grade 6 to Grade 10. More girls
than boys believe that their body is too fat, while more boys than girls see their body as too thin.
Rates with advancing grade remain relatively stable in boys (within 5 percentage points) but
increase sharply in girls (up to 13 percentage points) with advancing grade, such that, by Grade 10,
39% of girls believe their body is too fat. The percentage of girls who believe their body is too fat
represents a far greater percentage than girls who are overweight or obese. [Figure 7]

Figure 7 - Students who think their body is too thin, about the right size, or too fat, by grade and gender (%)

Substance use and risky behaviour

Adolescence is a formative stage of child development. During the adolescent years, many lifelong
health habits are established. It is also a period of experimentation with smoking, alcohol, and
drugs and other risky behaviours. For most adolescents, these behaviours are occasional in nature
and a normal part of growing up. However, for a sizable minority of adolescents, these behaviours
escalate and become more serious problems.

Cannabis use in Canada represents an area of increasing public health concern. Percentages of
students reporting ever using cannabis have increased between 1990 and 2002, with slightly
lower rates from the 2002 peak reported in the last two HBSC cycles. In 1990, approximately one
in four students in Grade 10 had used cannabis at some point in their lifetime. By 2002, the rate
of cannabis use doubled in boys and
increased to two-fifths of girls. Rates of
cannabis use have since declined to 40%
in boys and 37% of girls in 2010. These
findings suggest that cannabis use
should continue to be a priority in health
education curricula and related
policies. [Figure 8]

Figure 8 - Grade 10 students who have ever tried cannabis, by gender and year of survey (%)

Bullying and fighting

Bullying is a form of repeated aggression where there is an imbalance of power between
the young person who is bullying and the young person who is victimized. Power can be
achieved through physical, psychological, social, or systemic advantage, or by knowing
another's vulnerability (e.g., obesity, learning problem, sexual orientation, family background)
and using that knowledge to cause distress. Young people who are victimized tend to have
high levels of emotional problems, while young people
who bully tend to have the highest levels of behavioural
problems. Young people who are involved in both bullying
others and being victimized tend to have elevated levels of
both emotional and behavioural problems, with this group
of young people having the highest level of emotional
problems and the second highest level of behavioural
problems. Thus negative outcomes are differentially
associated with types of bullying involvement, while
young people who both bully others and are bullied are
at a particularly high risk for emotional and behavioural
problems. Figure 9 illustrates the findings for emotional
problems; see 2010 HBSC report for behavioural
problems.

Figure 9 - Students reporting high levels of emotional problems by bullying involvement, by gender (%)

Summary

While the full report contains information on a wide range of contexts and health
behaviours/health outcomes, the focus is on mental health. As such, in this summary, we
consider how these other factors are connected to mental health.

In examining the connections between contextual factors and mental health, one key theme
emerges: Interpersonal relationships matter. No matter how mental health is measured and no
matter what interpersonal relationship is concerned, adolescents with positive interpersonal
relationships tend to fare better in terms of mental health. At home, ease of communicating
with father and with mother, having relatively few arguments with parents, and sitting down
to eat as a family are all linked with improved mental health. At school, crucial elements related
to mental health include academic achievement, school climate, teacher support, and peer
support. With peers, engaging in positive activities is a protective factor for mental health,
while engaging in negative activities is a risk factor. Ease of talking to friends proves a two-edged sword with positive connections to emotional problems but negative connections to
behavioural problems.

The relationship between health behaviours and mental health shows two kinds of patterns. In
the first pattern, the health behaviour demonstrates similar connections to mental health for
both genders. Physical activity injury, for instance, is related with better emotional well-being
for girls and boys. Healthy living factors consistently connect to mental health with better results
for engaging in physical activity, eating fruits, and eating vegetables, and poorer results for
engaging in sedentary activity, consuming sugared soft drinks, and eating at fast food restaurants.
Adolescents who see themselves as too fat or too thin and adolescents who are trying to lose
weight have lower levels of emotional well-being. Smoking and being involved in bullying link
to greater behavioural and emotional problems; being involved in bullying is also a risk factor
for poorer emotional well-being with adolescents who both bully and are bullied being at
greatest risk.

Often, however, the pattern of relationships is more complex than seen in the first pattern.
For example, reports of injuries are related to behavioural problems for both genders but
to emotional problems only for girls. Fighting injuries connect negatively to emotional
problems and emotional well-being for boys, with increasing severity as measured in days
missed increasing the likelihood of negative outcomes. This relationship is inconsistent for
girls. BMI measures relate much more strongly with emotional problems and emotional
well-being for girls than they do for boys. Similarly, binge drinking and cannabis use have
stronger negative relationships with mental health for girls when compared to boys,
while having had sex links to poorer emotional well-being for girls but better emotional
well-being for boys.

Complicating these relationships is the issue of causality. It is unclear in these cases
whether the health behaviour leads to the mental health outcome or the mental health
outcome leads to the health behaviour. Most likely, there is reciprocal causation with
regard to health behaviours and mental health. Reciprocal causation suggests that we need
a multi-pronged approach to the issue, such that we ignore neither health behaviour nor
mental health outcome under the likely false impression than ameliorating the one will
directly have positive effects on the other.